Timor, Cuba - and the making of a medical superpower

Every year Cuba, a Majority World country of only 10 million people, sends more than 30,000 volunteer medical workers to 93 countries around the world. Surgeon Katherine Edyvane recounts the little-told story from first-hand experience.

Although I had met Cuban medical workers in other situations, it was during a recent one-year assignment as surgeon advisor to the Dili National Hospital in Timor-Leste that I learned more about the scope and intent of Cuba’s huge international medical aid effort.

In November 2007, I was fortunate to be part of a Timorese Ministry of Health team evaluating the 30-bed district hospital in the remote district of Oecussi (population 57,000). This is an enclave of Timor-Leste, located within Indonesian-governed West Timor – a district so remote that the only access for the average Timorese is via a weekly 12-hour ferry trip from the capital, Dili.

Our team was lucky to fly into Oecussi. We were slightly unsettled to hear from the Kiwi pilot of our small plane that we might have to make several attempts at landing, due to the invariable presence of goats grazing on the grass-and-gravel airstrip. After a relieved but bumpy landing (without a goat in sight), we made our way to the Oecussi district hospital, an old Portuguese-style villa located on a main street lined with beautiful, shady, ancient fig trees.

Cubans were the only doctors staffing the hospital and the outlying remote clinics in the mountains. From them I heard, first-hand, of their tremendous work and extreme hardships.

Hardships

One 25-year-old GP had lived and worked for the last two years in a mountain village eight hours’ walk from the hospital. He spoke of the unwell patients he had seen, many of them children, suffering from malnutrition, gastroenteritis, pneumonia, TB, hepatitis, malaria and surgical problems like hernias, appendicitis, peritonitis, bowel obstruction and advanced malignancies, such as breast cancer. While he was able to treat patients with infectious diseases, he felt helpless with those who needed hospital treatment or surgery, as most were too unwell to walk the eight hours to the hospital. His living conditions were also difficult – but, remarkably, he did not complain. He lived in a small room attached to the clinic, with a single gas-burner stove and electricity for only four hours in the evening – which meant there was no fan or air-conditioning for the oppressive tropical heat overnight, no screens for insects other than a mosquito net over the bed, and no television. For transport there was a single mini-van for the 30 Cuban doctors in the district.

A 50-year-old Cuban intensive-care specialist worked at the Oecussi district hospital. While he had experienced similarly difficult conditions, his only complaints were of cultural isolation and homesickness. He lamented that in the last two years he had not gone to a good party with rum, music and dancing – and he feared for his sanity.

The Cuban doctors are better adapted to the difficult living conditions in Timor-Leste than most Western medical missions would be – a fact which partially reflects conditions back home in Cuba, where the average doctor earns only 400 pesos ($20-30) a month. This is an important motive for Cuban doctors who choose to work overseas. In Timor-Leste they are paid $200 a month by the Cuban Government, and at the completion of a standard two-year term there is also a $4,000 bonus. The Government of Timor-Leste contributes accommodation, transport, phone cards and food rations.

History

The influence of Cuba here dates back to at least 1975, when Indonesia invaded Timor-Leste, nine days after it proclaimed independence from Portugal. During the next 25 years the resistance movement based much of its socialist ideology and guerrilla tactics on Fidel Castro’s revolutionary struggle. The influence is most apparent in the famous image of Che Guevara, which remains a symbol for the Fretilin Party. Anyone travelling to Timor today will be amazed at the sheer number of murals and T-shirts depicting Che.

Cuba’s physical involvement in Timor-Leste began in 2003, when President Xanana Gusmao met Fidel Castro in Kuala Lumpur at a conference of non-aligned countries. Faced with a critical shortage of doctors in Timor – prior to independence, most doctors had been Indonesian – Castro offered 50 scholarships for study in Cuba. Since then the number of scholarships has risen to 1,000, with an estimated 700-800 Timorese students presently in Cuba. A small number is also being trained in Dili using the ‘university without walls’ model, a Cuban-devised, community-based training programme.

Cuba first began sending medical teams to Timor in early 2004. Its largest contingent, in 2006, comprised about 300 doctors, numerous nurses and allied health professionals. Given that more than 80 per cent of the population live outside the major cities of Dili and Baucau, by far the most important contribution has been long-term services to the remote areas of the country. No other country has had the personnel to achieve a similar feat.

The history of Cuba’s large medical workforce begins in 1959. At the start of Fidel Castro’s revolution most of its doctors fled to the US. By necessity it had to train a large number of its own doctors. Since then the Government has focused on developing and maintaining a first-class universal healthcare system, actively encouraging its youth to pursue training in the health sciences and putting no restrictions on the number of doctors it trains. As a consequence, Cuba now has the highest number of doctors per capita in the world: in 2005 it had one doctor for every 159 people.

International

Cuba has helped many in its own region and around the world, sending out much-needed doctors and training medical students in Cuba. In 2005 there were 12,000 medical students from 83 countries, all on scholarships paid for by the Cuban Government – 1,600 overseas doctors graduated. In the next 10 years Cuba intends to ‘up-scale’ and train a further 10,000 a year – 100,000 in all. (Australia, whose population of 21 million is almost double that of Cuba, trains 1,500 a year.) While many of the foreign students in Cuba are from Central and South America, the Caribbean and Africa, the list also includes 60 Hispanic and African-American students from the US who cannot afford the fees of private medical schools at home.

According to Fidel Castro, the driving force has been solely humanitarian. While other countries may aim to become military superpowers, Cuba aims to become a humanitarian medical superpower

When Hurricane Katrina was predicted to hit Cuba in August 2005 a large medical taskforce was mobilized. In the event, Katrina caused only minor damage in Cuba. But few may know that, soon after the hurricane struck the southern states of the US, the Cuban Government offered the US Government immediate medical assistance – which was refused.

Several weeks later, Cuba announced the formation of the ‘Henry Reeve’ International Contingent, named after an American-born combatant who died on the battlefield in Cuba’s First War of Independence in the late 19th century. Within a month, Cuba was sending thousands of doctors to Guatemala after Hurricane Stan.

Then, on 8 October, a massive earthquake hit northern Pakistan, killing an estimated 75,000 people and injuring 120,000. At the time, Cuba had no embassy or consul in Pakistan. Already mobilized for Hurricanes Katrina and Stan, what followed was the most successful and massive medical response in Cuba’s history. Cuban medical teams were among the first to arrive on the scene. Of all the countries that contributed medical aid, the Cubans sent the largest contingent – 2,500 doctors and nurses, working in 30 mobile field hospitals and 14 other locations, treating more than a million people. Australia sent one military field hospital and a rotating team of two civilian doctors.

Motives

Over the years I have asked many Cuban doctors about their motives for volunteering to work in places like Timor-Leste. With few exceptions, the reasons cited are economic, clinical and humanitarian. Given the thousands of doctors training in a small country like Cuba, most new medical graduates have had little patient contact and specialists feel the need for more clinical exposure. In Pakistan in 2005 I met a Cuban surgeon who had worked for seven years in overseas missions to Venezuela, Guatemala and Angola. He said the only reason he continued was for the clinical experience. Back in Cuba, he explained, he had to compete with a dozen other surgeons for cases in his hospital.

Whatever one may feel about the politics of Cuba, the humanitarian drive motivating many Cuban doctors is undeniable. I remember, as a young final-year medical student working in Cuba in 1992, recognizing the Dean of the Medical School on TV – he was part of a work brigade picking bananas to assist farmers. This was during the time of the economic crisis, the so-called ‘Special Period’ after the collapse of the Soviet Union. Later, I jokingly told the Dean I had seen him on TV and that ‘I would love to see my Dean in Adelaide do the same thing’. His response was truly humbling: ‘I would never like to feel I am so important that feeding my people is a bad thing.’

This discussion would not be complete without some mention of the small number of dissatisfied Cuban doctors who, during their overseas attachments, have sought political asylum, mostly in the US. In Venezuela in 2007, 200 of the 10,000 Cuban medical workforce decided to seek asylum. In Timor-Leste in the last two years 9 out of 302 have done so.

While one can only speculate as to their reasons, they doubtless include a combination of economic grounds and the desire to travel. It is true that Cuban doctors are severely restricted in their ability to travel overseas. Castro defends this position by saying that the state has trained and invested in these doctors and their work is important to Cuba. One must also consider the very large carrot dangled by the US Government, granting Cuban asylum-seekers immediate residency, with virtually no questions asked. This courtesy does not extend to the hundreds of thousands of Haitians, Mexicans, Central and South Americans, and other asylum seekers who are deported every year from the US.

According to Fidel Castro, the driving force behind Cuba’s expanding international medical workforce has been solely humanitarian. While other countries may aim to become military superpowers, he says, Cuba aims to become a humanitarian medical superpower.

Katherine Edyvane is a general surgeon from Fremantle, Western Australia. She has worked in and visited Cuba on many occasions, and worked with Cuban doctors in Pakistan and Timor-Leste. In Timor she was working on a Royal Australasian College of Surgeons international aid project and was funded by the Australian Government (AusAid).

I had the opportunity to attend a medical conference, to supplement our knowledge on medical malpractice law. There was one session, where a panel of doctors and surgeons who came from overseas humanitarian work and shared the same experience cited in this article. One of them mentioned that it was an eye opener for him to be in presence of doctors and nurses who risked their lives for a profession that could have otherwise paid them more than what they're are earning overseas. He said, the experience is beyond words and no amount of money could easily replace or pay for it.

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